About one in five Medicare patients who are hospitalized end up bouncing right back within 30 days, so reducing unnecessary hospital readmissions has become a bit of a holy grail.

The 2010 health reform law includes new penalties for hospitals that have particularly high rates of repeat Medicare patients — sometimes called “frequent fliers” — for three specific diseases. The law also creates incentives and programs through Medicare for hospitals to improve discharges and the transition from the hospital back to the community — where lots of things can go wrong and do go wrong, setting the stage for that patient to go home and ricochet right back in.

Now a major multicity Medicare quality initiative, highlighted this week in The Journal of the American Medical Association, has reduced readmissions by nearly 6 percent compared with similar communities over two years. The authors estimate that in an average community with 50,000 Medicare patients, spending $1 million on relatively simple steps to curb hospitalizations would save $4 million per year on hospital bills alone. That would add up fast if these programs were to spread nationwide.

And improving care in the community didn’t just slow readmissions. It reduced all Medicare hospitalizations, not just those round trips.

“We didn’t just bend the [cost] curve — we turned it down, enough to be convincing,” study co-author Joanne Lynn, a leading geriatrician now at the Altarum Institute’s Center for Elder Care and Advanced Illness in Washington, told POLITICO.

Lynn noted that most of the study period was before the health care law passed so the communities weren’t responding to any new carrots or sticks in the legislation. Rather, she said, the health professionals and organizations that partnered with the Medicare Quality Improvement Organizations realized, “It feels good to work in a system that works and doesn’t hurt people.”

The JAMA researchers reported, too, that the improvements were quite consistent — in very poor and more affluent communities, in places that are big spenders on health care and those that are more sparing. That the readmission reductions were seen in the poorer communities helps push back against a school of thought that readmissions are an intractable problem, rooted more in poverty than in health care itself.

The solutions that these communities found included linking medical and social services — so that if Aunt Sally went from hospital to home, she’d be connected to various agencies that work with the poor or the elderly so she’d get meals, and a ride when she needs to see the doctor. They also made a point of teaching patients and families to do more self-care; in one pilot city, Tuscaloosa, Ala., faith leaders took that on as a mission, and local churches ran workshops on how people could better manage their own or their relatives’ chronic diseases, said Jane Brock of the Colorado Foundation for Medical Care, a co-author.